Abstract

Cerebrospinal fluid fistula represents one of the most dangerous but rare complication, in the spinal
surgery, with a high risk of morbidity for meningitis too. Its treatment results difficult for the high
incidence of relapses. As regards to the rehabilitation, the presence of the cerebrospinal fluid fistula
implies great care, related to the entity of the possible neurological damage, which could hesitate
also in paraplegia. Many treatments were described in literature for the repair of dura mater defects;
we report our experience about the treatment of the cerebrospinal fluid fistula through the use of
three local fasciocutaneous and muscular flaps, opposed and overlapped.

Keywords: Cerobrospinal fluid fistula; Z-plasty; Local flaps

Introduction

Cerebrospinal fluid fistula, a rare and dangerous complication, could, often, be associated with
an infection and a dehiscence of the surgical wound, hesitating in great loss of substance of the
middle line, also with a high risk of morbidity for meningitis. This complication could be potentially
dangerous for patient’s life and its treatment results difficult for the high incidence of relapses [1-3]. Many treatments were described in literature as regard to dura mater defects reconstruction
and cerebrospinal fistula closure. These treatments differ from simple direct suture, the use of
TISSUCOL and SURGICELL, grafts from fascia lata and muscular flaps associated or not with a
ventriculostomy and cerebrospinal fluid derivation [4].
As regards to the soft tissues defect covering, associated with cerebrospinal fluid fistula, many
Authors described the use of local fasciocutaneous flaps in addition to muscular flaps like latissimus
dorsii, trapezium, gluteus maximus and the paraspinal muscles [5].

Case Series

From October 2001 till now at the Policlinico Umberto I hospital, ten patients were referred
to the plastic surgeon inpatient clinic. Eight of them affected by cerebrospinal fluid fistula and two
by lymphatic fistula. They were evaluated at baseline and after 1, 3, 6 and 12 months according
to our protocols. Patients were verbally informed about treatment procedures, benefit limits, side
effects, and alternative treatment options and then all of them signed the consent form, before the
procedure, allowing taking clinical pictures. The study was performed as an analysis produced by an
extrapolation of data, coming from our routine medical records.
The final outcome was recorded by a visual evaluation made by plastic surgeons, taking into
account also the patient’s perception. The cerebrospinal fluid fistula, as result of laminectomy,
was treated in all cases with a direct suture of the dura mater, covering it with SURGICELL and
TISSUCOL and with cerebrospinal fluid drainage maintained for at least 15 days. We decided to
utilize this procedure to avoid recurrences of the fistula by avoiding the formation of dead spaces,
where the liquor could expand and start creating new fistulas, as we observed in all the cases never
treated with this peculiar kind of surgery. After a thorough debridment of the defect, we prepared
two sacrospinal muscular flaps from each side, which were sutured together through a Z plasty, to
replace the defect made by the previous laminectomy. Afterward, we covered the muscular layer
with two lumbo-dorsal fascial flaps and with two cutaneous flaps, all sutured with a Z plasty.
All muscular, fascial and cutaneous flaps were placed opposed in
different layers, in way that sutures weren’t in continuation between
them. For each anatomic layer, that is submuscular, subfascial and
subcutaneous ones, we placed aspirative drainages. We removed
them on the 2nd, 7th and 15th day respectively.
All patients were submitted to antibiotic therapy based on
bioptical intraoperative finding. We planned follow-up visits after
1, 3, 6, 12 and 24 months from the surgical treatment, so we can
determine the effectiveness of this surgical procedure with long term
results.

Results

Patients were six men and four women aged from 30 to 72 (average
58,8 ; mean 70 years). The basis pathology was in six cases a lumbar
stenosys localized at level L3-L5, in two cases a spondylolisthesis
of the tract L3-L5 and in other two cases a tethered cord syndrome
associated with a lombosacral lipoma. We observed the relapse of
the fistula during the 15th-18th day; therefore, we decided to repair it another time by using three local fasciocutaneous flaps above
muscular flaps, opposed and overlapped. All patients submitted
to follow-up visits after 1, 3, 6 and 12 months from the surgical
treatment have a complete resolution of the cerebrospinal fluid and
lymphatic fistula. We didn’t observe intra-operative or post-operative
complications. In each patient we observe a good posture, without
changes by functional deficit, absence of pain and a good aesthetic
result.

Figure 5

Figure 6

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Figure 6
Deep closure with sacrospinal muscular and fascial flaps.

Discussion

Surgical treatments suggested for the resolution of cerebrospinal
fluid fistulas foresee the use of wide muscular flaps as the latissimus
dorsii, the trapezium and the gluteus maximus that, in most cases,
could give serious postural and functional deficit [6].
We suggest a surgical treatment that restricts the rotational degree
and the muscular movement almost maintaining all the muscular
bone insertions so that we could limit the functional deficit. The scar
sequelae areas formed on the dura mater, cooperate in the closure of
the fistula and avoid the formation of dead places, that could be areas
of gathering for liquor, by the formation of a kind of “pseudodura”.
We think that the particular order of the three muscular, fascial
and cutaneous flaps overlapped and placed in a way in which sutures
don’t have continuity between them, could create a sort of tissue
barrier that could avoid the creation of a linear transit for the leakage
of liquor. Sutured areas represent the place with less resistance, their
placement could create areas easily crossed by the liquor. As regard
rehabilitation, we observed an earlier return to daily activities, with
minimal human and economic waste.
In the end, the reduced upsetting of layers surrounding the
lesion limits the postural changes and the following rehabilitative
restoration will result less difficult (Figure 1-6).